Job Description
Description Summary: Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, The Coding team and Health Information Management Department to ensure clinical documentation is complete and accurate and reflects severity of illness and resource utilization. Participates in the education of all members of patient care team on documentation guidelines, on an on-going basis.
Responsibilities - Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Accurately performs admission reviews for specific patient populations using clinical documentation guidelines. Communicates with ancillary personnel (e.g., PT, RT etc.) to clarify potential documentation opportunities. Extensively reviews all physician and clinical documentation, lab results, diagnostic information, treatment plans and captures appropriate information in 3M. Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption. Effectively communicates with appropriate physician(s) to ensure documentation opportunities are clarified. Utilizes AHIMA approved format to post physician queries 100% of the time.
- Updates 3M to reflect any changes in patient status, procedures/treatments. Accurately updates 3M to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate. Effectively confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures. Meets the benchmark of 90% physician agreement rate and 90% physician response rate. Follows the process for unanswered queries.
- Collaborates with coding staff as needed to determine appropriate DRG and required documentation. Provides clinical expertise and references to the coding staff as needed. Follows established guidelines for reconciling final coded DRG with the CDI DRG assigned at the time of discharge.
- Remains current with and conducts on-going education regarding the clinical documentation integrity program. Assists with the education of new staff, including new clinical documentation specialists, physicians, nursing and allied health professionals. Tracks and trends personal performance using 3M data. Attends and participates in educational conferences. Participates in concurrent performance improvement activities and on-going MR review activities. Reviews individual 3M data in conjunction with established benchmarks.
- Maintains positive and open communications with physicians, interdisciplinary care team members, Department Head, Lead Clinical Documentation Specialist, coding management and coding staff.
- Maintain and Model Nuvance Health Values.
- Demonstrates regular, reliable and predictable attendance.
- Performs other duties as required.
Education Skills Experience - Registered Nurse (RN) with 5 years recent experience in medical/surgical, critical care, intensive care or emergency room care preferred.
- BS or above preferred.
- Current NY/CT RN Licensure required.
Other Information - Must have strong interpersonal and communication skills.
- Ability to form positive, collaborative relationships with physicians and hospital staff.
- Must have analytical abilities to assist in obtaining solutions to problems.
- Must be able to work independently and prioritize work.
- Must be able to manage multiple priorities.
- Must be computer literate and willing to learn how to use computer applications relative to the job.
- Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
Working Conditions Manual: significant manual skills/motor coord & finger dexterity
Occupational: Little or no potential for occupational risk
Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force
Physical Environment: Generally pleasant working conditions
Company: Nuvance Health
Org Unit: 1767
Department: Clincial Document Improvement
Exempt: Yes
Salary Range: $45.29 - $84.11 Hourly
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